<!DOCTYPE html>
<html>
<head>
	<title>胖友报名申请通道</title>
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<body class="Contact">
   <div class="box">
      <div class="title">
         胖友报名申请通道
      </div>
      <form id="myform" action="http://mail.jszjrzk.com/bmi/kuaisu" method="post">
      <ul class="form">
         <li class="clear">
            <div class="left">姓 名：</div>
            <div class="right">
               <input id="name" type="text" name="name"/>
            </div>
         </li>
         <li class="clear">
            <div class="left">年 龄：</div>
            <div class="right">
               <input id="age" type="text" name="age"/>
            </div>
         </li>
         <li class="clear">
            <div class="left">性 别：</div>
            <div class="right">
               <label class="radio"><input type="radio" checked="checked" name="sex" value="男"/> 男</label>
               <label class="radio"><input type="radio" name="sex" value="女"/> 女</label>
            </div>
         </li>
         <li class="clear">
            <div class="left">身 高：</div>
            <div class="right">
               <input id="height" type="text" name="hegiht"/><span>CM</span>
            </div>
         </li>
         <li class="clear">
            <div class="left">体 重：</div>
            <div class="right">
               <input id="weight" type="text" name="weight"/><span>K g</span>
            </div>
         </li>
         <li class="clear">
            <div class="left">并发症：</div>
            <div class="right">
                <div class="select">
                   <div class="text"></div>
                </div>
                <div class="option">
                   <label class="clear"><input type="checkbox" name="bingfa[]" value="糖尿病"/><span>糖尿病</span></label>
                   <label class="clear"><input type="checkbox" name="bingfa[]" value="高血压"/><span>高血压</span></label>
                   <label class="clear"><input type="checkbox" name="bingfa[]" value="高血脂"/><span>高血脂</span></label>
                   <label class="clear"><input type="checkbox" name="bingfa[]" value="睡眠呼吸暂停症"/><span>睡眠呼吸暂停症</span></label>
                   <label class="clear"><input type="checkbox" name="bingfa[]" value="多囊巢综合症"/><span>多囊巢综合症</span></label>
                   <label class="clear"><input type="checkbox" name="bingfa[]" value="骨关节炎"/><span>骨关节炎</span></label>
                   <label class="clear"><input type="checkbox" name="bingfa[]" value="其他"/><span>其他</span></label>
                </div>
            </div>
         </li>
         <li class="clear">
            <div class="left">减肥经历：</div>
            <div class="right">
                <div class="select">
                   <div class="text"></div>
                </div>
                <div class="option">
                   <label class="clear"><input type="checkbox" name="jingli[]" value="节食"/><span>节食</span></label>
                   <label class="clear"><input type="checkbox" name="jingli[]" value="运动"/><span>运动</span></label>
                   <label class="clear"><input type="checkbox" name="jingli[]" value="中药"/><span>中药</span></label>
                   <label class="clear"><input type="checkbox" name="jingli[]" value="减肥药"/><span>减肥药</span></label>
                   <label class="clear"><input type="checkbox" name="jingli[]" value="减肥代餐"/><span>减肥代餐</span></label>
                   <label class="clear"><input type="checkbox" name="jingli[]" value="抽脂"/><span>抽脂</span></label>
                   <label class="clear"><input type="checkbox" name="jingli[]" value="火罐"/><span>火罐</span></label>
                   <label class="clear"><input type="checkbox" name="jingli[]" value="针灸"/><span>针灸</span></label>
                </div>
            </div>
         </li>
         <li class="clear">
            <div class="left">减肥效果：</div>
            <div class="right">
                <div class="select">
                   <div class="text"></div>
                </div>
                <div class="option">
                   <label class="clear"><input type="radio" name="xiaoguo" value="无效"/><span>无效</span></label>
                   <label class="clear"><input type="radio" name="xiaoguo" value="有效"/><span>有效</span></label>
                   <label class="clear"><input type="radio" name="xiaoguo" value="反弹"/><span>反弹</span></label>
                   <label class="clear"><input type="radio" name="xiaoguo" value="更胖"/><span>更胖</span></label>
                </div>
            </div>
         </li>
         <li class="clear">
            <div class="left">家庭条件：</div>
            <div class="right">
               <input id="tiaojian" type="text" name="tiaojian"/>
            </div>
         </li>
         <li class="clear">
            <div class="left">所在地：</div>
            <div class="right">
               <input id="address" type="text" name="address"/>
            </div>
         </li>
         <li class="clear">
            <div class="left">电 话：</div>
            <div class="right">
               <input id="phone" type="text" name="phone"/>
            </div>
         </li>
         <li class="clear">
            <div class="left">微 信：</div>
            <div class="right">
               <input id="wechat" type="text" name="wechat"/>
            </div>
         </li>
      </ul>
      <div class="footer clear">
         <input id="sub_btn" type="button" value="提交申请" name=""/>
         <input id="reset_btn" type="reset" value="重新填写" name=""/>
      </div>
      </form>
   </div>
</body>
</html>